In 2014, 1.7 million fee-for-service Medicare beneficiaries were admitted to skilled nursing facilities (SNFs) for post-acute care. These Medicare beneficiaries comprise a medically, psychologically, and socially vulnerable group and, following SNF discharge, many of them fare poorly and are rehospitalized. Little is known, however, about the factors that influence how older adults transition into the community after receiving post-acute care in SNFs. The candidate's career development goal is to become a leading expert on optimizing the transition of older adults from the SNF to home. The Training Objectives are: Objective 1, Obtain expertise on patient-level factors affecting an older adult's ability to transition across health settings and maintain independence; Objective 2, Obtain expertise on how in-home and outpatient health services utilization is associated with the ability of older adults to remain in the community following the SNF-to-home transition; and Objective 3, Obtain expertise in designing and conducting an intervention to help older adults transition from the SNF to home. The candidate's long-term research goal is to develop an intervention that optimizes the SNF-to-home transition and helps maintain the independence of older adults. To realize this goal, the candidate will conduct three separate, but related studies. Study 1 will link administrative databases (e.g., Minimum Data Set, Physician Part B File, Outcome and Assessment Information Set) for New York State Medicare beneficiaries (n=1,850,000). Study 2 will examine data from a longitudinal study of SNF rehabilitation residents (n=120). Studies 1 and 2 consist of secondary data analyses for which multivariable regression analyses will examine patient factors (encompassing physical, psychological, and social health domains) and healthcare utilization patterns that affect an older adult's ability to transition to and remain in the community. Study 3 consists of developing a care transitions intervention to pilot test in 40 residents being discharged from an SNF. The Research Aims are thereby: Study 1 Aim, Use Medicare data to examine the relationships between patients' capacity and health needs, their use of outpatient and in-home health services, and the number of days at home following SNF discharge; Study 2 Aim, Use data from a longitudinal study of SNF short-stay residents to characterize the association of physical functioning, depression, cognitive impairment, and social isolation with the patients' transition to and ability to remain in the community; and Study 3 Aim, With guidance from an Advisory Panel of consumers, caregivers, and SNF and community providers, develop and pilot test a care transitions intervention (intervention development Stages Ia and Ib, respectively). The candidate is based at University of Rochester, which has the experts in geriatrics, gerontology, health services, and community-based interventions necessary to ensure the success of these K23 activities. Findings from these activities will inform a community-based efficacy study (Stage III) that will be powered to examine the care transition intervention's effect on helping older adults remain in the community following SNF discharge.